Multiple geriatric syndromes in community-dwelling older adults in China

This study aims to assess the prevalence of geriatric syndromes and identify factors associated with multiple geriatric syndromes in community-dwelling older adults in China. We utilized a convenience sampling method to recruit older adults and from one rural and one urban community in Chengdu, China, from October 2022 to March 2023. A total of 706 older adults aged 60 years or older were included. Ten geriatric syndromes were investigated including two mental disorders: depressive symptoms, cognitive impairment; and eight somatic disorders: pain, falls, sleep disturbance, constipation, polypharmacy, multimorbidity, malnutrition and frailty. Multiple geriatric syndromes were defined as an individual having two or more geriatric syndromes. The data obtained were analysed using descriptive statistics. The independent risk factors for multiple geriatric syndromes were assessed using a logistic regression model. This study found that 90.5% of the participants had at least one geriatric syndrome, with 72.8% experiencing multiple geriatric syndromes. The top four geriatric syndromes in our study were polypharmacy (58.5%), malnutrition/at risk of malnutrition (43.1%), multimorbidity (42.1%), and frailty/prefrailty (34.3%). Of the older adults, 368(52.1%) had only somatic disorders, 18(2.5%) had only mental disorders and 253 (35.8%) had somatic-mental disorders. According to the logistic regression analysis, residence, age, marriage, BMI, and self-related health were significantly associated with multiple geriatric syndromes among older adults. This study highlights that multiple geriatric syndromes are prevalent among community-dwelling older adults in China, and underscores the significance of certain demographic factors in their occurrence. Future longitudinal studies are needed to establish the temporal relationship between multiple geriatric syndromes and these demographic factors, as well as to explore causal relationships and effective prevention strategies for geriatric syndrome.

on the prevalence and risk factors of individual conditions such as frailty 13 , depression 14 , sarcopenia 15 , cognitive risk 16 , nutritional risk 17 and so on in Chinese older adults, respectively.Few studies focus on multiple geriatric syndromes and related factors.
It is worth highlighting that certain geriatric syndrome symptoms are particularly prevalent and greatly impacted by long-term care, such as, mobility disorders (remain secluded, or bedridden), falls, incontinence, and cognitive impairment and the COVID-19 pandemic has further exacerbated the risks faced by the geriatric population 18 .Addressing these issues promptly through early intervention is essential and should be a focal point in geriatric care strategies 19 .A systematic review has revealed that sarcopenia is associated with adverse outcomes, including elevated mortality rates, functional decline, increased fall risk, and increased hospitalizations, making it a substantial public health burden within the geriatric population 20 .The medical burden in the older population over 90 years could influence general health status significantly, with a high prevalence of chronic diseases and geriatric syndromes 21 .Furthermore, the limited time that primary care physicians typically spend with each patient 22 , is often insufficient for comprehensively assessing the complex needs of a geriatric patient, highlighting the need for improved approaches to care for this vulnerable population.
The objective of screening is to utilize an interdisciplinary team to identify and treat geriatric syndromes in order to prevent further functional decline or morbidity.This allows for the implementation of comprehensive and targeted interventions.Awareness and recognition of geriatric syndromes among older individuals can enhance patient-centered care and significantly improve healthcare outcomes.Therefore, the present study aimed to assess the prevalence of geriatric syndrome and identify multiple geriatric syndrome-related factors among older adults in China.

Sampling and recruitment
We utilized a convenience sampling method to recruit older adults in Chengdu, China, from October 2022 to March 2023.We selected one rural and one urban community based on geographical convenience.The study targeted older adults living in the community, and an information letter was provided to all eligible individuals.The research team collected data after obtaining their consent and signatures on the study's informed consent form.The study protocol was approved by the Ethics Committee of West China Hospital, Sichuan University in 2022 (Ethics No. 861).All methods were performed in accordance with the relevant guidelines and regulations.
During the study period, all older adults who met the following criteria were included: (i) age ≥ 60 years and (ii) willingness to collaborate with the researchers after the purpose of the research was explained.The exclusion criteria were as follows: mental disorders (Alzheimer's disease, Schizophrenia), severe and end-stage diseases (expected life < 12 months, that with an established life-limiting condition or in receipt of end of life palliative care services 23 ).Convenience sampling was employed and the sample size was calculated using the following formula 24 : where n = minimum required sample size.Z = 1.96 at 95% Confidence Interval (CI).P = prevalence of multiple geriatric syndrome among the elderly, 40.2% 25 .q = 1-p.e = margin of error, 5% Based on the calculated sample size formula, a minimum of 369 participants was required to ensure a representative sample.The study ultimately included 706 older adults, thus enhancing the data's robustness and the study's generalizability.

Procedure and data collection
The research team was composed of research nurses and the first author.Before the start of the formal data collection, the first author provided training and education to 2 research nurses on how to complete the questionnaire accurately and consistently.There was an assessment at the end of the training, and the 2 nurses who were employed as the research nurses in the study had similar assessment scores, ages, years of experience, levels of education, and job titles.Finally, these 2 nurses were able to complete the questionnaire with unified introduction and questioning method during the formal investigation to ensure consistency among investigators and reduce data collection errors caused by different questioning methods among investigators.The interview was conducted directly with older adults face to face or by telephone.

Sociodemographic variables
We designed a questionnaire to collect sociodemographic data from the participants.The variables included age, sex, height, weight, marital status, resident, educational level, and self-related health.
For the classification of educational level, we defined three categories: low (with less than 9 years of education), middle (with 9 to 12 years of education), high ((with more than 12 years of education).To calculate the Body Mass Index (BMI), we used the following formula: BMI = weight (in kg)/height 2 (in m 2 ).Based on the calculated BMI, the participants were divided into different categories: severely underweight (BMI less than 16.5 kg/m 2 ), underweight (BMI under 18.5 kg/m 2 ), normal weight (BMI greater than or equal to 18.5 to 23 kg/m 2 ), overweight (BMI between 23 and 24.9 kg/m 2 ), and obese (BMI greater than 25 kg/m 2 ) groups 26 .

Geriatric syndromes
The geriatric syndromes included two mental disorders (depressive symptoms, cognitive impairment), as well as eight somatic disorders (pain, falls, sleep disturbance, constipation, polypharmacy, multimorbidity, malnutrition, and frailty).These geriatric syndromes were chosen because of their high prevalence in older adults [1][2][3] .The specific measurement scales/tools and methods for each geriatric syndrome are detailed in Table 1.The study defined multiple geriatric syndromes as the coexistence of two or more geriatric syndromes.The diagnosis of elderly syndrome is evaluated by the research nurses using the measurement scales/tools, and a general practitioner makes a diagnosis based on the evaluation results (Table 1).Older adults who had one or more somatic disorders and none mental disorders were divided into somatic disorders group; older adults who had one or two mental disorders and none somatic disorders were divided into mental disorders group; older adults who had both one or two mental disorders and one or more somatic disorders were divided into somatic-mental disorders group.

Statistical analysis
All data were categorical variables.To describe the demographic information, descriptive statistics were presented as counts and percentages.The Statistical Package for the Social Sciences (version 24.0) was used to enter and analyse the counts and percentages.The chi-squared test was utilized to evaluate the association between demographic information and self-related health with the presence of multiple geriatric syndromes.Statistical significance was set at P < 0.05 (two-tailed).To enhence clinical interpretability, adjacent groups with similar clinical significance and a sample size of less than 5% within the group were merged.
A Logistic regression model was conducted using the multiple geriatric syndromes as dependent variables and other factors as independent variables.The B, SE (standard error), Wald, 95% CI, and P values were reported.The results of the model were presented as odds ratios (ORs) with 95% confidence intervals (CIs).

Results
In our study, 706 older adults were evaluated, with an average age of 70.75 ± 7.39 years.The majority (56.5%) lived in urban community, 42.9% were female, 21.7% had a high education level, 88.5% were married, 36.3% had normal weight, and 75.2% reported self-related good health.
Among the participants, 67(9.5%) did not have any geriatric syndromes.The most prevalent geriatric syndromes were polypharmacy (58.5%) and malnutrition/ at risk of malnutrition (43.0%).Regarding the distribution of geriatric syndromes, 368(52.1%)older adults had only somatic disorders, 18(2.5%) had only mental disorders Table 1.The measurement scales/tools and methods for geriatric syndromes in our study.

Depressive symptoms
Patient Health Questionnaire-9 (PHQ-9) in Chinese, which consists of 9 questions that are based on the 9 DSM-IV criteria for a major depressive disorder, including anhedonia, depressed mood, sleep disturbance, fatigue, appetite changes, low self-esteem, concentration problems, psychomotor disturbances, and suicidal ideation 27 Depressive symptoms were assessed by the the scores for each PHQ-9 item range from 0 (not at all) to 1 (several days), 2 (more than half of the days), and 3 (nearly every day).Furthermore, the PHQ-9 is validated as a depressive symptom severity measure (5-9: mild depression, 10-14: moderate depression, 15-19: moderately severe depression, and 20-27: severe depression) 28 .In our study, a score > 5 was used as the cut-off Cognitive impairment the Mini-Mental State Examination (MMSE) in Chinese, which is a 30-point questionnaire used extensively in clinical and research settings to measure cognitive impairment, including simple tasks in a number of areas: the test of time and place, the repeating lists of words, arithmetic such as serial subtractions of seven, language use and comprehension, and basic motor skills 29 Mild cognitive impairment (MCI) was identified using education-specific cut-off points of total scores of MMSE: MMSE ≤ 19 for illiterate individuals, ≤ 22 for participants with elementary school education, and ≤ 26 for those with middle school education and above 30

Somatic disorders
Pain Wong-Baker FACES Scale (WBS) to measure pain level A score > 0 was used as the cut-off 31 Fall Record the number of falls in the past year Having at least one fall was classified as being a faller

Sleep disturbance
Participants were asked about the number of hours they actually slept on a typical night in the past month Five or fewer hours was used as the cut-off 2,32,33 Constipation Rome-III criteria to measure constipation In the absence of functional constipation without laxative use, two or more of the criteria were at least two months prior to diagnosis: 1) two or fewer defecations in the toilet per week, 2) at least one episode of fecal incontinence per week, 3) history of retentive posturing or excessive volitional stool retention at least once a week, 4) history of painful or hard bowel movement at least once a week, 5) presence of a large fecal mass in the rectum at least once a week, and 6) history of large diameter stools that may obstruct the toilet at least once a week 34 Polypharmacy -Polypharmacy was defined as the current use of five or more prescription and over-the-counter medications 35 Multimorbidity -Multimorbidity was defined as an individual having two or more current chronic diseases 36 Malnutrition MNA-SF, a six-item instrument with a score range of 0 to 14 points 37 .The MNA-SF has been validated and shows good specificity and sensitivity for the diagnosis of malnutrition, especially in older adults 38,39 For the purpose of our study, participants were categorized into a group with normal nutritional status (12-14 points), individuals at risk of malnutrition (8-11 points), or malnourished individuals (0-7 points) 40 .The MNA-SF has been validated among elderly individuals in China and has extraordinary test characteristics 41,42 Frailty FRAIL scale, which includes five self-reported questions: Do you feel fatigued?Can you climb a flight of stairs?Can you walk a block without stopping?Do you follow up or treat more than 5 diseases?In the last 6 months, have you unintentionally lost 5% or more of your body weight?

Discussion
The purpose of the present study was to describe the prevalence of geriatric syndrome and multiple geriatric syndromes related factors among older adults in China.
Our findings indicated that several factors significantly associated with multiple geriatric syndromes in older adults, including residence, age, marital status, BMI, and self-related health.
In this study, we observed geriatric syndromes in 706 older adults in Chengdu, Southwest China.We found that 90.5% of older adults had at least one geriatric syndrome and 72.8% experienced multiple geriatric syndromes.The prevalence of specific geriatric syndromes varied significantly, from 58.5% for polypharmacy and 5.1% for fall.Our findings regarding frailty were consistent with previous research by Sanford 44 , which reported that 41.0% and 30.4% of 11,344 individuals ≥ 65 years old across Missouri met the screening criteria for prefrailty and frailty, respectively, and 28.1% screened positive for dementia.Another cross-sectional population-based study 45 , with a sample of 1,705 individuals aged 60 years old or older, between 2009 and 2010 in Brazil found that the prevalence of polypharmacy was 32%, which was lower than that in our study.The high prevalence of polypharmacy may attribute to that more than 1/4 older adults in china suffer from multiple chronic disease 46 .
In our study, we found that 514 older adults (72.8%) had multiple geriatric syndromes (≥ 2 geriatric syndromes), which was higher than the study by Yang 25 .Yang's study found that 40.2% of community-dwelling older adults with ≥ 2 geriatric syndromes 25 .The discrepancy in the prevalence of multiple geriatric syndromes may reflect underlying regional and lifestyle factors that warrant further exploration.A growing number of studies have focused on somatic and mental geriatric syndromes.In Veizi's study they found that the most common geriatric syndrome was incontinence (69%), followed by polypharmacy (60%) and depression (43%) 21 .A crosssectional study conducted in four community clinics in Moscow reported that a decline in instrumental activity of daily living score was identified in 34.8% of the patients, a risk of malnutrition in 25.8%, probable cognitive impairment in 8.6%, and symptoms of depression in 36.2% 47 .Our findings are consistent with previous studies showing somatic and mental geriatric syndromes prevalence were high.These contributes to public health policy and practice to rationally allocate medical resources in China.Several suggestions are proposed in our study: first, the government should improve the layout of elderly medical resources and establish a sound elderly medical service network based on primary health centres, with hospitals as the core; second, health technicians in primary health centres should adopt the conventional model of elderly comprehensive evaluation, comorbidity management model, and multidisciplinary team work model, provide medical treatment for elderly, and maintain and restore their functional status to the greatest extent possible.Poor/fair self-reported health can be associated with lower life satisfaction and mortality so as lead to multiple geriatric syndromes, clinicians must assess how the older adults subjectively view their own health 48 .Married older adults were less likely to suffer from multiple geriatric syndromes than those unmarried.Marriage provides several benefits, including a lower mortality risk, a source of self-esteem, a supportive relationship, shared household goods, and the opportunity to combined accumulated assets and wealth 49 .Individuals aged 60-69 years old were less likely to suffer from multiple geriatric syndromes than those aged 70 years old and older.Aging remains the main risk factor for multiple geriatric syndromes, and the association may be based on the physiological changes due to cellular senescence, chronic inflammation, and the imbalance in the cellular redox state 50 .
Interestingly, our findings indicated that older adults living in urban communities were less likely to experience multiple geriatric syndromes compared to those living in rural communities.Older adults living in rural communities are more likely to have multiple geriatric syndromes, possibly because food, water quality, and social care systems between rural and urban communities are different 51,52 .Furthermore, we observed that normal weight individuals were more prone to multiple geriatric syndromes compared to obese older adults, while overweight individuals were less likely to suffer from multiple geriatric syndromes compared to obese older adults.This finding may be attributed to the observation of frailty in older adults, with weight loss being a common component 53 .Thus, adequate nutritional status is a key point to consider when establishing preventive measures.It is high time for medical staff to strengthen early screening, intervention, and classification management of geriatric syndrome among older adults, particularly those who are older, unmarried, and reside in rural communities.Medical staff should utilize diverse methods and media to implement health educational programs for the elderly and their caregivers, focusing on topics such as nutritious diets, physical activity and fitness, mental health, and rational medication usage.This effort aims to foster a healthy lifestyle and enhance the overall health literacy of older adults.At the same time, a follow-up management for geriatric syndrome is important to provide care services throughout their life in older adults.
The current study aimed to provide valuable evidence for community nurses to prevent multiple geriatric syndromes among older adults.To achieve this, a large sample of 706 older adults from Southwest China was recruited.Additionally, two trained research nurses were used minimize differences in subjective observation.While our study provides valuable insights, it is not without limitations.Firstly, the cross-sectional study prevents the establishment of causal relationships.Secondly, as the study was conducted in a single city in China, the results may not be generalized to other regions in the country.Given these limitations, further research is warranted to confirm these findings and their broader applicability.

Conclusion
The findings of the current study indicated that geriatric syndromes, especially polypharmacy, malnutrition/ at risk of malnutrition, multimorbidity and frail/prefrail, were common among older adults.Over one third older adults had somatic-mental disorders and more than 70% had multiple geriatric syndromes (≥ 2 geriatric syndromes).In conclusion, older adults who were older, lived in rural communities, were unmarried, had a normal BMI, and had poor or fair self-reported health were more likely to have multiple geriatric syndromes.
This study highlights that multiple geriatric syndromes are prevalent among community-dwelling older adults in China, and underscores the significance of certain demographic factors in their occurrence.However, further longitudinal studies are needed to establish the temporal relationship between multiple geriatric syndromes and these demographic factors.Additionally, exploring causal relationships and effective prevention strategies for geriatric syndrome is essential to improve the health and well-being of older adults.

Table 2 .
Number of geriatric syndromes and percentages of associated conditions.

Table 3 .
Results of univariate analyses of associations between demographic factors and multiple geriatric syndromes in older adults.

Table 4 .
Logistic regression model of risk factors for multiple geriatric syndromes among older adults in the southwest of China.ref.: reference.